PE Center of Excellence Accreditation Enrollment Form

Overview of Process Steps:

Please complete this form to officially initiate the PE CoE Application process. Once the form has been submitted, an invoice will be generated.

While the two legal documents below are required to complete the accreditation process, the Mutual NDA must be signed before your institution can access the application platform.

Legal Documents:

Mutual NDA

Certification Agreement

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* 1. Name of Institution:

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* 2. Nickname of Institution (if applicable):

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* 3. Name of Healthcare System (if applicable):

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* 4. Institution Address:

Street:

City:

State:

Zip Code:

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* 5. Outside of the United States:

State/Region/County/ Territory/Province:

Country:

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* 6. What type of PE CoE will your institution be applying for (criteria linked here)

Comprehensive Care PE Center of Excellence

Regional Care PE Center of Excellence

Uncertain

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* 7. Institution's PERT Team Leader Contact Information:

First Name:

Last Name:

Credentials/Title:

Specialty:

Email Address:

Phone Number:

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* 8. Institution's Finance Contact Information (for invoicing and payment purposes):

Name:

Title:

Email:

Phone Number:

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* 9. Form of payment for the nonrefundable application fee:

Check

ACH

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* 10. Who should the legal documents be sent to for review and signature?

Contact Name:

Contact Email:

Contact Number:

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* 11. If applicable, please fill out other institutional members that will be involved with the application process:

Contact 1 First Name:

Contact 1 Last Name:

Contact 1 Email:

Contact 2 First Name:

Contact 2 Last Name:

Contact 2 Email:

Contact 3 First Name:

Contact 3 Last Name:

Contact 3 Email: